Malaria Journal

Background: Community case management has been scaled up nationally in Zambia over the last decade. However, there is limited evidence on how this nationwide implementation has affected febrile patients' access to malaria diagnosis and treatment in Zambia. Methodology: This study analyzed four rounds of Malaria Indicator Survey (MIS) data (2012-2021) to evaluate: 1) proportion of all-ages individuals with fever who sought treatment from a formal provider, 2) proportion of individuals going to CHWs over time, among those who sought treatment at a formal provider, 3) time duration between fever onset and treatment seeking at a formal provider, and 4) proportion of children <5 with malaria that received Artemether-Lumefantrine (AL) treatment. Mixed-effect logit models were employed to examine determinants of treatment-seeking behavior and factors affecting AL receipt among children <5 with malaria cases. Results: The proportion of febrile patients seeking treatment remained below 60% throughout 2012-2021, and AL receipt among children with malaria cases consistently stayed below 50%. The mean interval between fever onset and initial treatment-seeking encounter decreased from 2.42 days in 2012 to 1.71 days in 2021. Among formal care seekers, CHW utilization increased from 1.5% in 2012 to 10.0% in 2018 before declining to 3.2% in 2021. Longer walking time to the nearest health facility was associated with lower odds of treatment seeking, whereas CHW density was not associated with treatment seeking or AL receipt. Children who did not went to formal providers had lower odds of AL receipt than those who sought treatment from CHWs. Conclusion: Despite nationwide CCM scale-up over the last decade, significant barriers persist in malaria patients' access to diagnosis and treatment in Zambia. Our results indicate that while CCM coverage should be maintained and further expanded, additional complementary interventions are also needed to overcome remaining access barriers.

Transmission-blocking vaccines (TBVs) are a promising strategy to reduce malaria transmission by targeting parasite stages within the mosquito. However, parasite genetic diversity may limit vaccine efficacy. We used next-generation amplicon deep sequencing to identify non-synonymous single nucleotide polymorphisms (SNPs) in Pfs25 from 184 Plasmodium falciparum isolates from Senegal, Tanzania, Ghana, and Burkina Faso. Prioritized SNPs were introduced into P. falciparum via CRISPR-Cas9. For the G116C variant, gametocyte development was evaluated by microscopy and qPCR, and mosquito infectivity was assessed by SMFAs. We identified 26 SNPs, including 24 novel variants. Functional assays showed that the Pfs25 G116C mutation did not affect gametocyte development or exflagellation. SMFA showed no significant differences in oocyst prevalence or intensity between mutant and WT parasites. These findings highlight the importance of integrating genetic surveillance with functional validation to guide the development of effective transmission blocking interventions

All primary healthcare centers owned by the Ugandan government in the Western Region of Uganda were submitted to a questionnaire concerning current availability of POCT from the Essential diagnostic List 2 part 1a and 1b, and the African laboratory inventory done by African Society of Laboratory Medicine and AfricaCDC. The data from the questionnaire was then linked to open source geodata provided by TomTom, and population data to calculate and visualize the accessibility of captured POCT. Findings: Availability of POCT Malaria is almost 100%, HIV 68-90%, and >30% for a majority of the POCT in the EDL-2 panel. 90% of the population in Western Region live within 1 hour by car from most of the essential POCT. Figures in the complementary web-based application visualize the accessibility of POCT for Western Uganda. Diagnostic deserts are visualized. Interpretation: Access to POCT at primary health care facilities in western Uganda has expanded substantially over the past decades. The geo-mapping tool presented here could inform policy decisions on strengthening diagnostic capacity at the national, regional, and provincial level. Funding: Swedish Research Council and Infravis All supplementary materials and a preprint of this submission are available on our OSF repository https://osf.io/j7puk/.

Introduction Miltefosine is the only approved oral antileishmanial agent, but its use in women of childbearing potential (WOCBP) is restricted due to preclinical teratogenicity. Current labeling recommends contraception during treatment and for at least five months thereafter, based solely on its long terminal elimination half-life. This study re-evaluated the required contraceptive duration using an exposure margin-based approach. Methods Virtual populations were generated from anthropometric data of 382 Indian, 4,462 Eastern African, and 4,019 Brazilian WOCBP with leishmaniasis. Published population pharmacokinetic models were used to simulate miltefosine exposure following 14-42-day regimens for visceral leishmaniasis (VL), post-kala-azar dermal leishmaniasis (PKDL), and cutaneous leishmaniasis (CL). A developmental safety exposure threshold was derived from the rat no-observed-adverse-effect level (0.6 mg/kg/day for 10 days) and adjusted using a 10-fold safety margin. Contraceptive durations resulting in median residual post-contraception exposure (AUCEOC-{infty}) below this threshold were considered supportive of contraceptive discontinuation. Results The developmental safety exposure threshold was estimated at 2.5 mg{middle dot}day/L. Despite pharmacokinetic differences across geographical regions and disease manifestations, required minimum contraceptive durations were consistent: three months from treatment initiation for the 14-day regimen, four months for 21- and 28-day regimens, and five months for the 42-day regimen. For the 14-day regimen, a single dose of a long-acting injectable contraceptive administered at treatment initiation would provide sufficient coverage. Conclusion An exposure margin-based approach supports shorter contraceptive durations than current recommendations. For the 14-day VL regimen, three months of contraception may provide a practical alternative to current labeling.

Disseminating study results to participants is an ethical responsibility for researchers but remains uncommon in low- and middle-income countries, and participants preferences for receiving study results are poorly understood. This study examined study result dissemination preferences among pregnant women in a phase III malaria prevention trial in Papua New Guinea (PNG). Participants completed an interviewer-administered questionnaire (survey) assessing their interest in and motivation for receiving trial results and preferences for dissemination methods and content. Associations between participants characteristics and dissemination preferences were explored using multivariable logistic regression analysis. Of 1172 trial participants, 96.0% (1125/1172) completed the survey, and of these 99.6% (1121/1125) wanted to learn about the trial results. The main motivation factors driving participants interest were an acknowledgment of their contribution to research (51.7%; n=579) and a better understanding of the study (45.0%; n=505). Most participants (78.9%; n=884) wanted to learn about the trial findings through written summary and a group meeting with other participants at the nearest clinic (31.1%, n=349). Multivariable regression analysis indicated that participants from rural/peri-urban clinics were more likely to choose non-electronic media dissemination approaches such as a group meeting as compared to urban-dwelling participants. Frequently selected items (>50% of participants) for content included information regarding good results of the study, purpose of the study, medical treatment advances, results specific to me, and how study was conducted. There was heterogenicity in the preference for dissemination content: compared to urban clinics rural clinics are less likely to want to learn about how and why study was conducted and medical and scientific advances. Overall, the majority wanted to learn about trial results, highlighting the importance of integrating dissemination into research activities in PNG. Variation in preferences for mode and content of dissemination between study clinics suggests that dissemination activities could be tailored to local context and preferences.

Background: Despite several trials on the hematological outcomes of intravenous (IV) iron in pregnancy, only few have examined its effect on birth outcomes. We estimated the causal effect of IV-iron on moderate or severe anaemia and birth outcomes. Methods: Women presenting to routine antenatal care in Pakistan with haemoglobin <10 g/dL were eligible for treatment. We used target trial emulation (TTE) methodology to estimate the effect of IV-iron treatment within 14 days of anaemia identification, compared to no treatment, on anaemia status at follow-up. A modified TTE analysis examined birth outcomes at delivery for singleton pregnancies, including birthweight, size-for-gestational-age, and mortality. We conducted a separate TTE for each of five gestational-age periods and pooled the results of each TTE. Results: We screened 3115 pregnancies of which 1715 were eligible for IV-iron; 1043 participants were treated during pregnancy. Those who received IV-iron had half the risk of moderate or severe anaemia in pregnancy compared with no treatment (pooled relative risk (RR) 0.40; 95% confidence interval (CI): 0.27, 0.59). The pooled effect of IV-iron on stillbirth suggested an 83% risk reduction (95% CI 55-94%), and trends were similar for perinatal and neonatal mortality. Conclusion: IV-iron treatment improved haematological status in pregnant women and was associated with a large reduction in stillbirth. Given limited data from randomised trials regarding fetal death and treatment earlier in pregnancy, this study contributes important information to the potential benefit of IV-iron in contexts where anaemia and its sequelae are a major public health problem.

Introduction Safe and timely blood availability remains a major global health challenge, especially in low- and middle-income countries. Digital tools may accelerate donor contact, but digital reachability alone does not ensure that people will notice, trust and act on urgent requests to support blood donation efforts. We examined factors associated with anticipated engagement in digitally coordinated urgent blood-donor mobilisation among digitally reachable adults in Ghana. Methods We conducted a cross-sectional online survey from September 2025 to January 2026 across Ghana's 16 regions. Participants were recruited via Facebook advertising and snowball sampling. Factors associated with urgent blood-donor mobilisability were assessed under four criteria: high future-donation willingness; high willingness to install a trusted donation app; high willingness to respond to a trusted urgent-request; and high practical flexibility to leave current activities. Descriptive analyses and multivariable logistic regression examined prevalence and associated factors. Results Among 1,067 participants, 577 (54.1%) met all four criteria. Future-donation willingness (91.8%), trusted-app installation willingness (83.2%) and trusted-request response willingness (82.7%) were common, whereas practical flexibility was lower (66.6%). In the adjusted model, high formal health-system trust (adjusted OR (AOR) 3.95, 95% CI 2.08-7.50), high digital-response readiness (AOR 2.26, 1.66-3.08), previous donation (AOR 1.47, 1.08-2.01), high donation knowledge (AOR 1.42, 1.03-1.97) and willingness to donate to strangers were positively associated with high mobilisability. Women (AOR 0.60, 0.43-0.83), participants reporting a work-schedule barrier (AOR 0.43, 0.29-0.66) and those travelling over 30 min to the nearest healthcare facility at night (AOR 0.66, 0.45-0.96) had lower adjusted odds. Conclusions Digital reachability and stated donation willingness may overestimate the population pool available for emergency donation. Digital blood-donor solutions should consider verifiable health-system requests, account for response readiness and current availability, and connect willing individuals with accessible collection options and transport support where needed.

Background: Snakebite envenoming is a major cause of preventable death and disability in the Brazilian Amazon, where long distances, sparse roads, and dependence on river transport delay access to antivenom. We developed location-allocation models to identify community health centers that could strategically expand access to antivenom in Amazonas State, Brazil. Methodology/Principal Findings: We conducted an ecological geospatial study using a 2025 WorldPop population surface, locations of existing and candidate health facilities, and a multimodal road-and-river transportation network derived from OpenStreetMap and HydroSHEDS. Population demand was represented by 7,065 populated centroids, including 1,586 within Indigenous territories. We applied a maximize-coverage algorithm with a six-hour travel-time threshold. Two models were developed: one for Amazonas excluding Manaus and one for populations living in Indigenous territories. Both models began with 77 facilities already providing antivenom and progressively added candidate community health centers until coverage gains plateaued. The plateau occurred at 110 facilities, corresponding to 33 additional centers. In the model excluding Manaus, this configuration covered 1,118,831 people, or 75.11% of the target population; 87.61% of those covered could reach care within three hours. In Indigenous territories, coverage increased from 50.55% to 69.50%, reaching 50,434 people, of whom 81.39% were within three hours of care. Validation used 3,595 snakebite notifications from the 30 highest-burden municipalities in the Brazilian Notifiable Diseases Information System during 2023-2025. The median proportion reaching care within six hours was 40.81% in observed data and 72.17% in model estimates. Conclusions/Significance: Strategically equipping 33 additional existing community health centers could substantially expand timely access to antivenom, particularly in rural and Indigenous areas. Location-allocation modeling that incorporates river transportation can support evidence-based decentralization of time-sensitive health services in geographically complex settings.

Background. Nigeria carries one of the world's largest burdens of neonatal death and remains far from the Sustainable Development Goal target. Whether health financing and macroeconomic instability are associated with newborn survival has rarely been examined for neonatal mortality specifically. Methods. We conducted an ecological time-series analysis of national annual data, covering 1990-2024 for macroeconomic models (n = 35) and 2000-2023 for health-financing models (n = 24), the periods for which published data exist; no values were imputed. Neonatal mortality came from the UN Inter-agency Group for Child Mortality Estimation 2025 round with 90% uncertainty intervals, and other series from the World Development Indicators. The primary model regressed log neonatal mortality on government health expenditure per capita (purchasing power parity), out-of-pocket share and currency instability, with a linear trend, a post-break trend spline and Newey-West standard errors; first differences without trend terms were the main sensitivity analysis. The break was located by segmented regression; currency instability was tested under four constructions. Results. The decline broke around 2010, the trend moving from -0.74 to +0.14 deaths per 1,000 annually (F = 145.4, p < 0.001). The subsequent rise fell within estimation uncertainty (2012: 37.6, 90% interval 33.9-41.5; 2022: 39.3, 33.4-46.4), supporting stagnation rather than reversal; Demographic and Health Surveys concur, reporting 42 per 1,000 for the five years preceding the 1990 survey and 41 preceding the 2024 survey. Government health expenditure per capita was inversely associated with neonatal mortality (-0.040, 95% CI -0.051 to -0.029, p < 0.001; first differences -0.016, p = 0.033) and was the only expenditure measure surviving both specifications; share-of-GDP measures did not (p = 0.196 and 0.889) and correlated positively in raw terms. Currency instability showed no association under any construction (p = 0.65-0.83). Public expenditure per capita moved non-monotonically, peaking in 2005, falling by 2010 and recovering by 2023 to a level still below the 2005 peak. Conclusions. Neonatal mortality in Nigeria is ecologically associated with public health expenditure per capita, but not with commonly used share-based measures, nor with currency instability. Rising public spending accompanied stalled progress, directing attention toward how health resources are converted into services. Annual modelled mortality estimates could not support year-to-year inference, a limitation relevant to comparable studies

Background: Sickle cell anaemia (SCA) is characterised by chronic haemolysis, inflammation, platelet activation, and recurrent vaso-occlusive complications. Mean platelet volume (MPV) is a readily available platelet index, but evidence regarding its relationship with disease severity in paediatric SCA remains limited and inconsistent, particularly in African populations. Objective: To evaluate the relationship between MPV and disease severity among children with SCA in Kwara State, North-Central Nigeria. Methods: This hospital-based cross-sectional study included 51 clinically stable children with confirmed SCA consecutively recruited from the paediatric haematology clinic of Children Emergency Specialist Hospital, Ilorin. Complete blood count, including MPV, was performed using a Rayto RT-7600 automated haematology analyser. Disease severity was assessed using a composite clinical and laboratory scoring system based on a previously described method. Pearson's correlation, Spearman's rank correlation, simple linear regression, and the Kruskal-Wallis test were used as appropriate. Statistical significance was set at p < 0.05. Results: Of 51 participants, 14 (27.5%) had mild, 33 (64.7%) moderate, and 4 (7.8%) severe disease. Mean MPV was 9.34 +/- 0.76 fL (range, 8.0-11.2). Pearson's correlation showed a weak positive, non-significant linear relationship with severity score (r = 0.231, p = 0.103), whereas Spearman's analysis showed a weak positive monotonic association (rho = 0.286, p = 0.042). Regression explained 5.3% of severity-score variation (R2 = 0.053, p = 0.103). MPV did not differ significantly across severity categories (H = 2.163, p = 0.339). MPV correlated inversely with haemoglobin (r = -0.556, p < 0.001) and positively with platelet count (r = 0.307, p = 0.029). Conclusion: MPV showed a weak relationship with disease severity but inconsistent statistical evidence across analyses. The limited explained variance and absence of significant differences between severity categories do not support MPV as a standalone severity marker. Larger longitudinal studies are warranted. Keywords: Sickle cell anaemia; Mean platelet volume; Disease severity; Platelet indices; Paediatric haematology; Cross-sectional study; Nigeria.

The erythrocyte sedimentation rate (ESR) is one of the most common and widely used laboratory diagnostic parameters in connection with inflammatory reactions and it is probable that every reader has already experienced a determination of their ESR. A rapid ESR is a non-specific parameter that provides information about the inflammatory process. Although the origins of this methodology date back to antiquity, the description of the process as the collapse of a percolating gel formed from erythrocytes has only recently been achieved. It was not yet known whether slow ESR has any medically relevant significance. Here we show a variety of clinical pictures that exhibit a systematically slow ESR (e.g., sickle cell disease, neuroacanthocytosis syndromes, chronic mountain sickness). Using a combination of measured data and physical modelling, we show how the accuracy and significance of ESR data can be increased. With this improved ESR (supraESR), we introduce a completely new, cost-effective diagnostic parameter, based on an established and easily automated measurement method, that enables low-cost screening for neuroacanthocytosis syndrome, a group of rare neurodegenerative diseases previously detectable only through complex diagnostic tests.

Background Dengue is a major public health challenge, and predictive models are crucial for early warning systems. However, many current modeling practices rely exclusively on climatic factors or employ complex algorithms that lack the interpretability needed for informed public health decision-making. To address these shortcomings, we developed and validated a multidimensional, interpretable statistical model to predict monthly dengue incidence. Methodology/Principal Findings We used a Generalized Linear Mixed Model (GLMM) with a Negative Binomial distribution to analyze 14 years (2010-2023) of spatiotemporal data from 37 municipalities in Huila, Colombia, an endemic region. The model integrates non-linear and lagged effects of climatic, demographic, and socioeconomic factors. The final model underwent rigorous external validation on an independent test set (2021-2023). Our model demonstrated high predictive discrimination (R2 = 0.743, Spearman's {rho} = 0.657), accurately capturing the timing of epidemic outbreaks. Key findings include the identification of an optimal thermal window for transmission at 27-28{degrees}C, a threshold effect for precipitation above 800 mm, and a saturation dynamic in outbreak autocorrelation. Conclusions/Significance This mechanistically-informed statistical approach provides a robust and transparent tool for epidemiological surveillance, successfully balancing high predictive performance with the explanatory power needed for effective, data-driven public health interventions.

Motivation: With the scaling frequency and intensity of extreme heat events across the globe, it is critical for public institutions to develop early detection systems and continuous monitoring of these events and their impacts. In Brazil, Rio de Janeiro was the first city to publish its heat protocol, with the Rio Heat Dashboard as a central component of this system. Implementation: The dashboard was implemented using R/Shiny and integrates climatic and health data from multiple sources. General features: The application comprises real-time heat exposure monitoring and automatic alert level classification, which is monitored daily by multiple municipal actors and supports activation of actions specified in the heat protocol. It also features a health impact module, which lists each heat event and its impact on mortality, and primary care and emergency visits. Availability: The source for full reproducibility is available through https://github.com/joaohmorais/RioHeatDashboard.

Background Birth Preparedness and Complication Readiness (BPCR) education is an important component of antenatal care. However, health education materials translated from one language into another may lose their intended meaning if linguistic, cultural, experiential, and sociolinguistic differences are not considered. In Tanzania, maternal health education is commonly delivered in Swahili, while many source materials are developed in English. This study explored the cultural and linguistic equivalence of BPCR terminology and concepts in a translated Swahili BPCR education manual among Hehe pregnant women in the rural Iringa Region, Tanzania. Methods A descriptive qualitative study was conducted in seven villages across Kilolo and Mufindi districts of Iringa Region. Seven focus group discussions (FGDs) involving 56 pregnant women were conducted. Participants were purposively selected from the Hehe community and were asked to interpret terminology and concepts contained in a harmonized Swahili BPCR education manual. The translation and adaptation process comprised six sequential steps: forward translation, synthesis, back translation, expert review, community exploration, and finalization. FGDs were conducted in Swahili by trained facilitators fluent in both Swahili and Hehe, audio-recorded with consent, transcribed, and thematically analyzed using Braun and Clarkes six-phase approach. Analysis focused on semantic, conceptual, experiential, and sociolinguistic equivalence. Reporting was informed by the Consolidated Criteria for Reporting Qualitative Research (COREQ). Results Five themes were developed: (1) culturally and linguistically familiar expressions conveyed BPCR concepts; (2) experiential and contextual language shaped descriptions of danger signs; (3) sociolinguistic norms and modesty influenced communication about sensitive health topics; (4) some clinically important concepts had partial or limited conceptual equivalence; and (5) unfamiliar concepts required supplementary explanation. Participants identified culturally familiar expressions including "matazamio ya kujifungua" ("anticipated date of delivery"), "fedha ndiyo usafiri" ("money itself is transport"), "chupa imepasuka" ("the water bag has burst"), "mtoto kutokucheza tumboni" ("the baby is not moving in the womb"), and "sehemu za siri" ("private parts"). Some expressions were familiar but broader than their biomedical equivalents, while cord prolapse and neonatal cyanosis had no readily recognized community equivalents. Conclusion The findings indicate that cultural and linguistic equivalence cannot be achieved through literal translation alone. Community exploration identified expressions that were familiar and socially acceptable while also revealing clinical concepts requiring additional explanation. The findings informed refinement of the Swahili BPCR education manual while preserving the intended clinical meaning. The adapted terminology should subsequently be evaluated separately for its effects on knowledge, attitudes, practices, and other health outcomes.

Background: Exclusive breastfeeding may protect infants against common infections and support healthy growth and development. Working mothers may face constraints on exclusive breastfeeding arising from work schedules, separation from their infants, and inadequate breastfeeding support. National evidence on the individual, healthcare-related, and contextual factors associated with exclusive breastfeeding among working Ghanaian mothers appears to remain limited. Design: Cross-sectional secondary analysis. Setting: Nationally representative survey covering urban and rural communities across all 16 administrative regions of Ghana. Participants: The analysis included 620 currently working mothers whose youngest living infants were aged 0-5 completed months and lived with them. The complete-case multivariable analysis included 619 mother-infant pairs. Primary outcome measure: Current exclusive breastfeeding, defined using the standard 24-hour infant-feeding indicator. Infants were classified as exclusively breastfed when they received breast milk without water, formula, animal milk, other liquids, or solid or semi-solid foods during the preceding day or night. Oral rehydration solution, vitamins, minerals and prescribed medicines were permitted. Aim: To estimate the prevalence of exclusive breastfeeding and examine its individual, healthcare-related and contextual correlates among working mothers of infants aged 0-5 months in Ghana. Methods: Birth Recode data from the 2022 Ghana Demographic and Health Survey were analysed. Unweighted frequencies and survey-weighted percentages described the study population. Design-adjusted Wald tests assessed bivariate associations. Survey-weighted binary logistic regression estimated adjusted odds ratios (AORs) and 95% confidence intervals (CIs), accounting for sampling weights, primary sampling units, and strata. Results: The survey-weighted prevalence of exclusive breastfeeding was 54.3% (95% CI: 49.2-59.3). Ethnicity, mode of delivery, region, and community poverty appeared to be statistically significant in the bivariate analyses. In the adjusted model, region was jointly associated with exclusive breastfeeding (p = 0.004). Mothers in the Northern (AOR = 4.93; 95% CI: 1.5-16.17) and Savannah (AOR = 4.22; 95% CI: 1.08-16.41) regions had higher odds than mothers in the Western Region. Mothers in low-education communities had lower odds than those in high-education communities (AOR = 0.54; 95% CI: 0.30-0.98). Although Guan mothers had higher odds than Akan mothers, the overall association with ethnicity was non-significant, and the estimate appeared imprecise. Maternal age, individual education, religion, parity, wealth, infant sex, antenatal care, postnatal care, and residence were not independently associated with exclusive breastfeeding. Conclusion: The prevalence estimate suggests that slightly more than half of working mothers exclusively breastfed their infants. Regional and community differences appeared more pronounced than those associated with most measured individual characteristics. Regionally responsive breastfeeding support and practical community education may contribute to improved coverage. Workplace recommendations require further evidence because employment conditions were not measured directly. Keywords: Exclusive breastfeeding; working mothers; infant feeding; maternal employment; regional inequalities; community education; Ghana; 2022 Ghana Demographic and Health Survey; survey-weighted analysis.

Public genomic repositories can support antimicrobial resistance (AMR) surveillance, but unequal sampling can bias interpretation. We characterised AMR determinants, multicountry genomic cluster overlap and surveillance gaps across Africa using an NCBI Pathogen Detection snapshot retrieved on 24 August 2026 for 55 African Union member states. Records were validated and deduplicated by BioSample, and complete AMRFinderPlus calls were summarised across five United Nations M49 subregions and eight overlapping regional economic communities (RECs). Country-pair cluster overlap was assessed using the Jaccard index, while project-based and composition-standardised sensitivity analyses evaluated repository bias. The dataset contained 86,829 unique BioSamples from 51 states; South Africa, Malawi and Kenya contributed 55.8%. Complete extended-spectrum {beta}-lactamase calls were detected in 21,513 isolates and carbapenemase calls in 4,642. blaCTX-M-15 dominated the ESBL profile, while NDM and OXA types predominated. Seventy clusters contained carbapenemase-positive isolates from at least two countries. A shared REC covered all participating countries in 38 clusters, while 32 crossed REC boundaries. Normalised country-pair overlap was low, with a maximum Jaccard index of 9.5%. Project balancing reduced the Northern African carbapenemase estimate from 32.3% to 17.9% and the Eastern African ESBL estimate from 36.9% to 12.5%. Public repositories identify determinants and clusters for investigation but do not estimate prevalence or transmission. AMR surveillance should combine national confirmation, regional institution-led investigation where countries share an REC, and continent-wide coordination through Africa CDC for cross-REC signals, supported by representative One Health sampling, standardised metadata and sustained African sequencing capacity.

Communities exposed to flooding can experience markedly different mental health outcomes, yet conventional resilience indicators capture only part of the social and contextual conditions that may explain this variation. This study develops a multilevel and predictive framework for examining community resilience and depressive symptoms following flood exposure in Indonesia. Data were drawn from 20,303 respondents aged 15 years and older nested within 312 communities in the Indonesia Family Life Survey (IFLS-5). Depressive symptoms were assessed using the 10-item Centre for Epidemiologic Studies Depression Scale (CES-D-10), with Rasch Partial Credit Model calibration used to examine measurement properties. Bayesian multilevel models quantified between-community heterogeneity and assessed how far observable structural resources accounted for this variation. Community resilience was represented through two complementary constructs: structural resilience, based on observable socioeconomic and social-capital resources, and Latent Community Protective Capacity (LCPC), a model-derived proxy for residual contextual variation in depressive-symptom risk. Approximately 6 percent of variation was attributable to between-community differences, while observable structural resources explained only part of this heterogeneity. Structural resilience and LCPC were weakly correlated (r = 0.155). Moderation analyses provided no clear evidence that structural resilience altered the flood-depression association, while LCPC showed a directionally consistent but uncertain buffering pattern. Predictive models incorporating community-level information improved discrimination, with the best-performing model reaching an ROC-AUC of approximately 0.71. The findings suggest that observable resource-based indices provide an incomplete account of community-level mental health vulnerability and that residual contextual measures may provide complementary information, while requiring cautious interpretation and independent validation.

Micronutrient deficiencies are prevalent in Madagascar, where diets rely heavily on starchy staples and access to animal-source foods is limited. Small dried fish (SDF) are widely available, yet their nutritional value and health risks remain poorly documented. We combined market surveys, taxonomic identification, and micronutrient and heavy metal analyses of nine SDF types collected along National Road 7. The samples encompassed 33 fish families, were dominated by small pelagic species (Clupeidae and Engraulidae), and were appreciated by consumers. A daily portion (5 g for infants; 10 g for young children and women of childbearing age) contributed substantially to Recommended Nutrient Intakes (RNIs). Across samples and groups, SDF were rich (>30% of RNI) in selenium and, for infants and young children, in calcium. All samples were a source of (>15% of RNI), or rich in, phosphorus, whereas iron contributions were more variable but often substantial. Several samples exceeded 100% of RNIs for selenium, calcium, iron, or manganese in infants and young children, and some were also sources of magnesium and, less frequently, zinc. Vitamin A was absent from sun-dried samples but detected in a smoked freshwater type. Heavy metal concentrations varied markedly, and portions of several types led to estimated exposures to inorganic arsenic or cadmium exceeding reference values, whereas freshwater species and some pelagic types showed a more favorable nutrition-risk balance. Overall, SDF are affordable, nutrient-dense foods with strong potential to alleviate micronutrient deficiencies in Madagascar, while highlighting the need for type-specific guidance to balance nutritional benefits and contamination risks.

Background Floods are among the most devastating natural disasters worldwide and are increasingly associated with adverse mental health outcomes, particularly Post-Traumatic Stress Disorder (PTSD). In December 2023, Hanang District in northern Tanzania experienced catastrophic mud floods that resulted in extensive loss of life, destruction of property, displacement of households, and disruption of livelihoods. While emergency humanitarian responses focused primarily on physical needs, limited evidence exists regarding the long-term psychological consequences among survivors. Therefore, this study aimed to determine the patterns of PTSD manifestations and assess cognitive factors associated with PTSD symptoms among flood victims in Hanang District, Tanzania. Methods A community-based cross-sectional study was conducted among 360 flood victims one year after the disaster. PTSD symptoms were assessed using the PTSD Checklist for DSM-5 (PCL-5). Descriptive statistics summarized PTSD severity, while chi-square tests and regression analyses examined associations between socio-demographic characteristics and PTSD manifestations. Cognitive factors were assessed based on participants' exposure to traumatic experiences and perceptions of traumatic events. Results The mean PCL-5 score was 39.2 (SD = 20.6), indicating a high burden of psychological distress. Approximately 45% of respondents had severe PTSD symptoms (PCL-5 [&ge;]45), while another substantial proportion demonstrated moderate symptom severity. PTSD manifestations varied significantly by geographical location (p < 0.001), household income (p = 0.011), and marital status (p = 0.002). Age positively predicted PTSD severity ({beta} = 0.019, p = 0.001), whereas household income negatively predicted symptom severity ({beta} = -0.297, p = 0.001). Exposure to natural disasters constituted the predominant cognitive factor, with 45% directly experiencing the flood and 38.3% witnessing the event. Exposure to secondary traumatic experiences through witnessing or learning about violent events was also common. Cognitive trauma exposure demonstrated a significant association with PTSD symptoms ({chi}2, p < 0.001). Conclusion PTSD remains highly prevalent among flood survivors in Hanang district. Both direct and indirect trauma exposure significantly contributed to PTSD manifestations. Comprehensive disaster recovery programmes should integrate trauma-focused psychological services, cognitive behavioural interventions, routine PTSD screening, and community-based psychosocial support alongside socioeconomic recovery initiatives.

Inappropriate antibiotic use presents a major global health challenge, particularly in low-resource settings where access to quality care is limited but antibiotics remain relatively unrestricted. This study estimates the causal effect of frontline primary care quality on inappropriate community antibiotic use, combining detailed community-based data from approximately 100 rural villages in rural China with an instrumental variable (IV) approach embedded within a double/debiased machine learning (DML) framework. We linked objective measures of village doctor clinical practice quality, measured through unannounced standardized patient visits, to household-level antibiotic use data collected from the same villages. To identify the causal effect, we constructed multiple candidate instruments from extensive provider characteristics and used an ensemble of machine learning algorithms within a flexible DML-IV framework to approximate an optimal instrument, addressing a many-weak-instruments problem. We found that improving village provider clinical practice quality reduced both antibiotic receipt during healthcare encounters for common diseases and household antibiotic storage for future self-medication. Our findings suggest that strengthening frontline primary care quality can meaningfully reduce inappropriate community antibiotic use without restricting access to essential treatment. More broadly, this study illustrates how causal machine learning can strengthen conventional causal estimation in complex observational settings in global health economics research.